| Initial hospital care low complexity CPT 99221 • Office Visits | $71 | $109 | $147 |
| Initial hospital care moderate complexity CPT 99222 • Office Visits | $113 | $136 | $159 |
| Initial hospital care high complexity CPT 99223 • Office Visits | $161 | $201 | $222 |
| Subsequent hospital care low complexity CPT 99231 • Office Visits | $61 | $86 | $111 |
| Subsequent hospital care moderate complexity CPT 99232 • Office Visits | $62 | $87 | $111 |
| Subsequent hospital care high complexity CPT 99233 • Office Visits | $103 | $107 | $111 |
| Hospital discharge day management 30 minutes or less CPT 99238 • Office Visits | $75 | $93 | $111 |
| Hospital discharge day management more than 30 min CPT 99239 • Office Visits | $106 | $126 | $136 |
| Consultation office low complexity CPT 99243 • Office Visits | $116 | $137 | $159 |
| Consultation office high complexity CPT 99245 • Office Visits | $184 | $234 | $285 |
| Blepharoplasty upper eyelid CPT 15823 • Ophthalmology | $601 | $601 | $601 |
| Foreign body removal external eye corneal CPT 65210 • Ophthalmology | $4 | $20 | $37 |
| Corneal transplant endothelial CPT 65756 • Ophthalmology | $1,130 | $1,130 | $1,130 |
| Trabeculoplasty laser surgery CPT 65855 • Ophthalmology | $233 | $233 | $233 |
| Trabeculectomy glaucoma filtering surgery CPT 66170 • Ophthalmology | $1,047 | $1,047 | $1,047 |
| Endoscopic cyclophotocoagulation CPT 66711 • Ophthalmology | $482 | $482 | $483 |
| Cataract surgery complex with intraocular lens CPT 66982 • Ophthalmology | $715 | $715 | $715 |
| Cataract surgery with intraocular lens insertion CPT 66984 • Ophthalmology | $323 | $323 | $323 |
| Intravitreal injection therapeutic agent CPT 67028 • Ophthalmology | $103 | $103 | $103 |
| Retinal detachment repair with vitrectomy CPT 67108 • Ophthalmology | $30 | $30 | $30 |
| Retinal photocoagulation treatment CPT 67210 • Ophthalmology | $495 | $495 | $495 |
| Retinal treatment extensive photocoagulation CPT 67228 • Ophthalmology | $30 | $178 | $326 |
| Strabismus surgery one horizontal muscle CPT 67311 • Ophthalmology | $462 | $462 | $462 |
| Blepharoptosis repair levator resection CPT 67901 • Ophthalmology | $425 | $425 | $425 |
| Lacrimal punctum closure by plug CPT 68761 • Ophthalmology | $127 | $127 | $127 |
| Eye exam new patient intermediate CPT 92002 • Ophthalmology | $83 | $83 | $83 |
| Eye exam new patient comprehensive CPT 92004 • Ophthalmology | $93 | $113 | $133 |
| Eye exam established patient comprehensive CPT 92014 • Ophthalmology | $113 | $113 | $113 |
| Visual field examination CPT 92083 • Ophthalmology | $26 | $40 | $54 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $24 | $24 | $25 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $40 | $44 | $48 |
| Fundus photography CPT 92250 • Ophthalmology | $20 | $25 | $30 |
| Arthrocentesis aspiration small joint CPT 20600 • Orthopedics | $47 | $47 | $47 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $36 | $56 | $77 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $57 | $60 | $63 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $1,654 | $1,654 | $1,654 |
| Lumbar spine fusion posterior approach CPT 22612 • Orthopedics | $1,545 | $1,545 | $1,545 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $1,801 | $1,801 | $1,801 |
| Total hip replacement CPT 27130 • Orthopedics | $1,254 | $1,254 | $1,254 |
| Hip replacement conversion to total CPT 27132 • Orthopedics | $1,631 | $1,631 | $1,631 |
| Open treatment femoral fracture CPT 27236 • Orthopedics | $1,166 | $1,166 | $1,166 |
| Treatment intertrochanteric fracture with plate/screw CPT 27245 • Orthopedics | $30 | $30 | $30 |
| Partial knee replacement medial or lateral CPT 27446 • Orthopedics | $1,127 | $1,127 | $1,127 |
| Total knee replacement CPT 27447 • Orthopedics | $1,253 | $1,253 | $1,253 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $30 | $299 | $568 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $459 | $608 | $865 |
| Arthroscopy shoulder rotator cuff repair CPT 29827 • Orthopedics | $1,045 | $1,045 | $1,045 |
| Arthroscopy knee with meniscectomy medial and lateral CPT 29880 • Orthopedics | $550 | $550 | $550 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $529 | $529 | $530 |
| Discectomy lumbar single level CPT 63030 • Orthopedics | $948 | $948 | $948 |